EMBRYONIC DEVELOPMENT IN VIRTUAL REALITY

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1 EMBRYONIC DEVELOPMENT IN VIRTUAL REALITY Melek Rousian

2 EMBRYONIC DEVELOPMENT IN VIRTUAL REALITY Melek Rousian

3 Embryonic development in virtual reality Thesis, Erasmus University Rotterdam, The Netherlands The research described in this thesis has been performed at the department of Obstetrics and Gynaecology, Subdivision Embryonic of development Obstetrics and in Prenatal virtual reality Medicine, Erasmus MC, Rotterdam, The Netherlands. Thesis, Erasmus University Rotterdam, The Netherlands The research described in this thesis has been performed at The the printing department of this of thesis Obstetrics has been and financially Gynaecology, supported Subdivision by the Department of of Obstetrics and Gynaecology and Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam, the The Department Netherlands. of Bioinformatics, Erasmus MC, Rotterdam, The Netherlands, Nederlandse Vereniging voor Obstetrie The printing en Gynaecologie of this thesis and the has J.E. been Jurriaanse financially Stichting. supported by the Department of Obstetrics and Gynaecology and the Department of Bioinformatics, Erasmus MC, Rotterdam, The Netherlands, Nederlandse Vereniging voor Obstetrie en Gynaecologie and Further J.E. support Jurriaanse for this Stichting. dissertation was kindly provided by: Further support for this dissertation was kindly provided by: Medical Dynamics Sorg-Saem Sorg-Saem Cover: I-Space virtual reality image of an early foetus at 11 weeks gestational age, by Melek Rousian and Anton Koning. It is remarkable how outer structures can be visualized. Cover: Lay-out I-Space and printing: virtual reality Off page, image an early foetus at 11 weeks gestational age, by Melek Rousian and Anton Koning. Copyright It is remarkable 2011 Melek how Rousian, many outer Alblasserdam, structures can The be Netherlands, seen. All rights reserved. No parts of this thesis Lay-out may be and published printing: Off or transmitted page, in any form or by any means, electronic, or mechanical, including photocopying, recording or reproduced without written permission of the copyright owner. Copyright 2011 Melek Rousian, Alblasserdam, The Netherlands, All rights reserved. No parts of this thesis may be published or transmitted in any form or by any means, electronic, or mechanical, including photocopying, recording or reproduced without written permission of the copyright owner.

9 PART 6 A SYSTEMATIC TOOL FOR DIAGNOSING FIRST 143 TRIMESTER CONJOINED TWINS Chapter 6.1 Diagnostic techniques and criteria for first trimester conjoined 145 twin documentation: a review illustrated by case reports PART 7 GENERAL DISCUSSION 169 PART 8 SUMMARY/SAMENVATTING 181 Part 9 AUTHORS AND AFFILIATIONS 191 PUBLICATIONS AND AWARDS 192 PORTFOLIO 194 WORD OF THANKS/DANKWOORD 197 All movies can be found on the following webpage:

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12 Part 1 Part 2 GENERAL INTRODUCTION

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14 Chapter 1.1 introduction

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16 1.1 INTRODUCTION Organogenesis, which represents first trimester growth and development of the embryo, gestational sac and trofoblast, is a fast and complex process. Many adverse exposures can disturb embryogenesis, affecting both subsequent fetal as well as postnatal health 1-3. Before investigating the impact of different factors on first trimester growth and development, it is of great importance to define normal embryonic growth and development. Human embryogenesis has been studied for centuries using in vitro specimen. Ronan O Rahilly and Fabiola Müller revised three milestone text volumes in which human embryology was systematically described by Wilhelm His ( ), Franklin Mall ( ) and George Streeter ( ), and updated their studies on the staging of human embryos 4. Franklin Mall started collecting embryos (miscarriage specimen) in 1887 and this became the basis of the Carnegie Collection (Mall and Meyer, 1921). O Rahilly and Müller s book Developmental stages in human embryos included a revision of Streeter s work and a survey of the Carnegie Collection 4. In their book the first 57 post-ovulatory days are described in detail using internal morphological, external morphological and histological criteria. This period is divided into 23 stages, and the last stage, stage 23 represents the end of the embryonic period, as at that moment all essential organ systems are present. Although the embryonic development has been studied in great detail using these stages, they are based on descriptions of in vitro specimen which is a marked disadvantage. Nowadays, in vivo visualization of the embryo is of vital importance for clinical care and in vivo research projects. It was not until 1957 when it became possible to visualize the embryo in vivo. After the introduction of medical ultrasound and the visualization of the first fetus with ultrasound, the resolution improved, transvaginal ultrasound was developed and growth parameters and growth charts were constructed rapidly, resulting in a new era for in vivo diagnosis and follow-up from early pregnancy onwards. These days, two-dimensional (2D) ultrasound examinations are performed routinely in the 2 nd trimester of pregnancy, when all organ systems of the fetus are screened for abnormalities 5. In the early first trimester ultrasound examinations are performed to confirm pregnancy location, viability and duration 6. The early fetus can be screened for a number of abnormalities in the first trimester NT screening period (between 11+6 and 13+6 weeks GA) Studies are performed to find out what the detection rates are of abnormalities during the early and late first trimester Secondly, these improvements facilitate the construction of new charts and standards regarding embryonic and early fetal growth and development. Another impressive development in the embryonic and fetal visualization has been the introduction of three-dimensional (3D) ultrasound in the 1980s. So far, the advantages seem mainly in the detection of external morphological abnormalities during the fetal period 13. Due to the small size of an embryo and early fetus the whole pregnancy fits in a single transabdominal or transvaginal 3D ultrasound sweep. The relative large amount of amniotic fluid surrounding 16

17 the embryo ensures high quality 3D ultrasound datasets, showing the embryo in great detail. Although it offers many advantages, 3D ultrasound datasets are still assessed using 2D media (like computer screens), which implies that the information concerning the third dimension is not presented and used optimally. Using a stereoscopic display or a virtual reality (VR) system allows optimal presentation of all three dimensions. A high-end VR system, like the Cave Automatic Virtual Environment (CAVE) 18 immerses viewers in a virtual environment, allowing depth perception and interaction with the displayed hologram. This technique can be a major step forward in visualizing 3D data. 1.1 INTRODUCTION In this thesis the use of VR in the assessment of human embryonic growth and development is described for which we have tentatively introduced the name virtual embryoscopy. The research objectives were: 1. To establish the reproducibility of new embryonic biometric and especially volumetric measurements performed using VR (part 2). 2. To study embryonic development (such as the embryonic brain) in more detail and to provide growth charts in relation to GA and the CRL for newly introduced biometric and especially automated volumetric measurements (parts 3 till 5). 3. To describe the possibility of in vivo staging of the embryo based on internal and external morphologic characteristics and to relate this to GA, CRL, embryonic volume and brain ventricle volume (part 5). 4. To evaluate the applicability of this technology for diagnosing congenital anomalies such as first trimester conjoined twins (part 6). REFERENCES 1. Barker DJ. The fetal and infant origins of adult disease. BMJ. 1990;301: Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Effect of in utero and early-life conditions on adult health and disease. NEJM. 2008;359: Mook-Kanamori DO, Steegers EA, Eilers PH, Raat H, Hofman A, Jaddoe VW. Risk factors and outcomes associated with first-trimester fetal growth restriction. JAMA. 2010;303: O Rahilly R, Muller F. Developmental stages in human embryos. Washington: Carnegie Institution of Washinghton Publication Chervenak F, Isaacson G, Campbell S. The obstetric ultrasound examination Boston: Little Brown Bottomley C, Van Belle V, Mukri F, Kirk E, Van Huffel S, Timmerman D, Bourne T. The optimal timing of an ultrasound scan to assess the location and viability of an early pregnancy. Hum Reprod. 2009;24: Nicolaides KH, Azar G, Byrne D, Mansur C, Marks K. Fetal nuchal translucency: ultrasound screening for chromosomal defects in first trimester of pregnancy. BMJ. 1992;304: Nicolaides KH, Brizot ML, Snijders RJ. Fetal nuchal translucency: ultrasound screening for fetal trisomy in the first trimester of pregnancy. BJOG. 1994;101: Brizot ML, Snijders RJ, Bersinger NA, Kuhn P, Nicolaides KH. Maternal serum pregnancy-associated plasma protein A and fetal nuchal translucency thickness for the prediction of fetal trisomies in early 17

22 BIOMETRY, VOLUMETRY AND STAGING Three-dimensional ultrasound Since the introduction of three-dimensional (3D) ultrasound during the 1980s hundreds of articles have been published in medical literature describing the application of this technique in obstetrics and prenatal medicine. A single 3D dataset acquired in the end first trimester allows for full off-line evaluation of standard anatomical landmarks 1. The multiplanar sectional plane mode is used, allowing the examiner to rotate the 3D dataset around three orthogonal axes, and to scroll through the datasets in order to obtain the required plane for checking and measuring the structure of interest (figure 1). The possibility of evaluating additional anatomical landmarks, besides the already used growth parameters (like the crown-rump length, gestational sac diameter, yolk sac diameter) during the early first trimester is nowadays being studied in detail; especially using 2D FIGURES AND MOVIES techniques 2-4. Once Figure a 3D 1. ultrasound A 3D ultrasound dataset has dataset, been obtained acquired using and stored a transvaginal (figure 2) probe, of an unique information can be collected by performing off-line volume calculations. Both hypoechoic 10+1 weeks and gestational hyperechoic age structures (GA) is shown can be in measured the multiplanar manually sectional and plane mod hypoechoic structures even semi-automatically, immediately on the ultrasound machine View or later application. a personal The computer A plane represents using specialized the coronal software. view, Examples the B plane of the axial vi volume measurements in the first trimester are placental volume, amniotic fluid volume, C yolk plane sac the volume sagittal and fetal view body of the volume embryo. (usually The without final image including shows the a 3D rende volume of the limbs) 2-5. The brain cavities can also be segmented and visualized, embryo. Figure 1. Figure A 3D ultrasound 2. A 3D rendering dataset, obtained by 4D using View a of transvaginal a nine-week probe, old of embryo. an at 10+1 weeks gestational age (GA) is shown in the multiplanar sectional plane mode of the 4D View application. The A plane represents the coronal view, the B plane the axial view and the C plane the sagittal view of the embryo. The final image shows a 3D rendering of the embryo. 22

23 1.2 BIOMETRY, VOLUMETRY AND STAGING Figure 2. A 3D rendering by 4D View of a nine-week old embryo. although most applications can not determine their volume due to the small size 5-6. Blaas et al. were able to measure the brain ventricle volume in the first trimester of pregnancy with an in-house developed system 7. The I-Space virtual reality system Three-dimensional ultrasound has many advantages compared to two-dimensional (2D) ultrasound. Unfortunately the 3D images are currently viewed and assessed using 2D media like ordinary computer screens. These 2D media do not offer depth perception, which is required for optimal interpretation of 3D and fourdimensional (4D) ultrasound images. On March 24 th, 2005 the department of Bioinformatics of the Erasmus MC in Rotterdam opened a Barco I-Space virtual reality (VR) system. The Erasmus MC I-Space uses passive 3D projection (i.e. based on polarization) to offer different images to the left and right eye. The two images show the same objects, but viewed from a slightly different angle. The brain is capable of constructing a single 3D image out of these two 2D projected images (figure 3). In the Erasmus MC eight Barco SIM5 projectors are installed behind or above the four projection screens (2.60 x 1.95 meters), which form the floor, left, right and front walls of the I-Space (figure 4). In every corner of this room an infrared camera (four in total) is installed for tracking purposes. The tracking system registers the position and orientation of the user s head, in order to provide him with the correct perspective, and a joystick. The wireless four-button plus hatswitch joystick is used to operate a specialized volume rendering application called V-Scope, which was developed to allow visualization of and interaction 23

24 BIOMETRY, VOLUMETRY AND STAGING Figure 3. Illustration of stereoscopic imaging in the I-Space. The two images are projected through two different filters, illustrated as a red filter and a blue filter. The observer wears glasses, and in these glasses similar filters (red and blue) have been placed. With the right (red) filter, only the light from the right projector is visible. With the left (blue) filter only the light of the left projector is visible. This forces the viewer to see a different image with each eye. Since it is in fact the same object, but viewed in a slightly different angle, this results in depth perception. The I-Space does not use red and blue filters, but circular polarizing filters, which have the same effect, but allow full color images to be viewed. 24

25 1.2 BIOMETRY, VOLUMETRY AND STAGING Figure 4. Picture of an observer (MR) in the Barco I-Space. An embryo of eight weeks GA is projected on the walls. with volumetric datasets, like 3D ultrasound, CT and MRI 8. The joystick emits a virtual pointer and is used to enlarge and rotate the hologram, and cut it with a clipping plane in any arbitrary direction. V-Scope also allows the user to change the grey scale, color and opacity of the data. In addition to the clipping plane a virtual eraser can brush away parts to get the best view of the object of interest. Finally, V-Scope also implements several tools to perform optimal biometric and volumetric measurements. It is possible to change the scale, orientation, grey scale, color and opacity of the data. The clipping plane and brush function enable the user to cut away or brush away parts to get the best view of the object of interest. In addition to these tools, it is possible to perform optimal biometric and volumetric measurements. Biometry An integrated tracing tool allows 3D length measurements by placing two or more measuring points (or calipers ). Standard biometric measurements like the crownrump length (CRL) (movie 1), biparietal diameter (BPD), occipito-frontal diameter (OFD) and abdominal diameter (AD) can be performed by placing two calipers 9. 25

26 Movie 1. This movie presents a CRL measurement performed at 10 weeks gestational age. The virtual pointer is used to perform the length measurement in the I-Space VR system. BIOMETRY, VOLUMETRY AND STAGING This technique is also valuable for non-standard biometric measurements like the width of the hip, knee, elbow, shoulder and the length of the ear and foot 9. The length of the umbilical cord and vitelline duct are measured by placing multiple calipers along the length of the structure (figure 5). The diameter and thickness of the cerebellum are measured using the same principle. Depth perception and 3D interaction enables measuring of new non-standard biometric parameters and verification of accurate placement of the calipers for precise and reliable measurements 10. As a result the use of VR may improve prenatal care. A B Figure 5. A screen shot of an I-Space hologram of nine weeks GA. The length of the vitelline duct (A) and umbilical cord (B) is traced. Volumetry A volume is defined as the amount of space that is present within an object or solid shape. The use of 3D ultrasound datasets enables volumetric measurements of structures during the first trimester of pregnancy. These measurements can be used as parameters for fetal growth. One way to obtain these measurements is to count the number of voxels in(side) a structure. A voxel, short for Volumetric Picture Element, is the 3D equivalent of the better known 2D pixel, and represents a value on a regular grid in three dimensional space (Source: Wikipedia). 26

27 As human beings are three dimensional, only a 3D dataset can fully capture all parameters of growth and development. 2D measurements (like the CRL) are just derived parameters. V-Scope allows the user to perform volume measurements using a semiautomated segmentation algorithm. This algorithm is based on a region-growing approach in combination with a neighborhood variation threshold, as originally proposed for MRI data by Myers and Brinkley 11. The algorithm has been modified to handle the speckles in ultrasound data by simplifying some of the parameters of the original algorithm and (optionally) smoothing the grey level data. The user selects an upper and lower grey level threshold and an upper threshold for the variance of the voxel s neighborhood. After placing a seed point the algorithm will segment (grow) the region by adding connected voxels that fall within the thresholds. Using this function, the volumes of hyperechoic and hypoechoic structures, like the gestational sac, brain ventricles and embryonic body, can be measured. Prior to a volume measurement, connections to other structures with the same gray value range have to be brushed away to avoid segmentation of other parts than the structure of interest. If a structure consists of both hyperechoic and hypoechoic parts, like the embryonic body, the segmentation must be performed in two steps. V-Scope can automatically add the segments and calculate the total volume. If the segmentation is not perfect, the user can place additional seed points, manually grow or shrink the segmented region or use the brush function to add or delete voxels from the segmented structure. 1.2 BIOMETRY, VOLUMETRY AND STAGING Staging The Carnegie Staging system has been used almost a century to describe human embryonic development The different stages are based on internal and external morphological and histological criteria, and do not include the gestational age and length of the embryo. Ultrasound can be used to study the embryogenesis in vivo (movie 2), but until now only possibilities of staging embryos based on some external morphological criteria have been evaluated 14. Movie 2. This 2D movie presents 3D ultrasound datasets of different embryos at different gestational ages as rendered by the V-Scope VR application. The observer (MR) uses different functions to get the best impression of the developing embryo. Abnormal growth and development The measurement of the crown-rump length (CRL) is the cornerstone in first trimester obstetric care and was described first by Robinson 2, If the CRL does not match the gestational age based on the last menstrual period, the duration of pregnancy may be different as result of a late ovulation or late 27

28 BIOMETRY, VOLUMETRY AND STAGING implantation. A discordant CRL measurement may also be an indication of early growth retardation 18, a pregnancy which is going to end as a miscarriage 19 or a chromosomal abnormality Recently, studies have shown that the maternal age, ethnic background of the mother and fetal sex also affect the CRL Additionally, variation in first trimester growth of the developing embryo can be caused by environmental factors such as nutrition (folate intake) and other life-style factors such as smoking 24. It is therefore important to perform the CRL measurement correctly and in case of abnormalities consider all possible explanations. This will aid in the detection of growth problems early in pregnancy. This thesis describes the possibility of first trimester prediction of intra uterine growth restriction in the second and third trimester using the CRL and embryonic volume. The V-Scope application is also being used to evaluate the clinical value of VR for early detection and description of embryonic and fetal congenital malformations. In different case studies the additional value of this approach is described Included in this thesis are three cases of conjoined twins. Depth perception allows optimal visualization of complex embryonic structures like the limbs and central nervous system. We plan to further study the possibilities of detecting embryonic defects early in pregnancy, especially in high risk patients due to their genetic and/or medical background, using this new technique. In conclusion, VR opens new ways of studying embryonic and early fetal growth and development in vivo. Secondly, biometry, volumetry and morphology can be studied optimally using VR. Applying these techniques may contribute to prenatal diagnostics being brought forward from the second and third trimester to the first trimester of pregnancy, entering a new area of embryonic medicine. REFERENCES 1. Fauchon DE, Benzie RJ, Wye DA, Cairns DR. What information on fetal anatomy can be provided by a single first-trimester transabdominal three-dimensional sweep? Ultrasound Obstet Gynecol. 2008;31: Robinson HP, Fleming JE. A critical evaluation of sonar crown-rump length measurements. BJOG. 1975;82: Blaas HG, Eik-Nes SH. Sonoembryology and early prenatal diagnosis of neural anomalies. Prenat Diagn. 2009;29: Grisolia G, Milano K, Pilu G, Banzi C, David C, Gabrielli S, Rizzo N, Morandi R, Bovicelli L. Biometry of early pregnancy with transvaginal sonography. Ultrasound Obstet Gynecol. 1993;3: Pistorius L, Stoutenbeek P, Visser GH. First trimester neurosonoembryology with automated follicle tracking: preliminary findings. J Matern Fetal Neonatal Med. 2009;22: Timor-Tritsch IE, Monteagudo A, Santos R. Three-dimensional inversion rendering in the first- and early second-trimester fetal brain: its use in holoprosencephaly. Ultrasound Obstet Gynecol. 2008;32: Blaas HG, Eik-Nes SH, Berg S, Torp H. In-vivo three-dimensional ultrasound reconstructions of embryos and early fetuses. Lancet. 1998;352: Koning AH, Rousian M, Verwoerd-Dikkeboom CM, Goedknegt L, Steegers EA, van der Spek PJ. V-scope: design and implementation of an immersive and desktop virtual reality volume visualization system. Stud Health Technol Inform. 2009;142: Verwoerd-Dikkeboom CM, Koning AH, Hop WC, van der Spek PJ, Exalto N, Steegers EA. Innovative virtual reality measurements for embryonic growth 28

VIRTUAL EMBRYOSCOPY Christine Verwoerd-Dikkeboom All previously published parts of this thesis have been reproduced with the explicit permission from the publishers. Printing of this thesis was financially

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